substance use disorders Flashcards
Trajectories
Transition from use to dependence
Alcohol: 15-23%, onset before age 30, 1:20 seek treatment
Nicotine: 68-32%, 5.1 % success rate per quit attempt
Cannabis: 9% within 10 years of initiation
Cocaine: 17-21% (for crack and iv use theres a higher risk)
Opioids: pill misuse 7.5%, heroin 23-30%, most persistent, often lifelong, periodic remissions common
Risk factor models
Biological
Host, environment, agent vs
Bio-psycho-social-spiritual
Risk factors (biological- host perspective): pre-natal exposure, family history, early onset use, response to use (pharmacokinetics, receptor density, sensitivity, risk alleles), regular use, progression to harder and more drugs, medical conditions, psychiatric illnesses/disorder
heritability
twin, family, adoption studies
Cocaine with the highest heritability of .65 to .79
Most substances around .4-.6
For nicotine: heritability for age of onset, amount smoked, persistence and cessation
phenotypic traits of children of fathers with alcohol addiction
B-endorphin response in relatives
Genetics
twin studies, linkage studies, GWAS, exome sequencing identify risk genes
Like HTN, DM and autism, polygenic risk factor model
Initially: looking for biological suspects: alcohol metabolizing enzymes, Mu opioid receptor polymorphism
GWAS: SNPs related to K+ signaling involved in subsance use d/o
Risks
Brain development, reward and risk is done by 13 but by 25 is when prefrontal cortex is done
Psychological and spiritual risk factors
Psych: Maturity (Stress tolerance), risk taking proneness, novelty seeking, rebelliousness, impulsivity, lack of emotional control, impressionability exposure to adevertisement, favorable attitude towars substance use, risk preception, psychological mindedness, interpersonal relatedness, LGBTQI
spiritual- self image/ self worth, goals for the future, accountability, religiousity
Risku drugs
Risky drugs: arrives at the reward center quickly (oral vs smoking)
Binds receptors tightly, activates receptor fully, activates the reward center strongly (cannabis vs heroin), leaves the brain quickly (fentanyl vs methadone)
Risky drug and risky environment
repeated exposure, ease of access, legal landscape, mediating relationships: drug and alcohol misuse increase risk of getting opioids prescribed
Prior drug and alcohol misuse increase risk for opioid misuse/ additction
social risk factors
Individual: trauma: ACE (Adverse childhood event)> 4: 10 x more likely ivdu >6:46, post natal stress- think epigenetics
Parental warmth, attitude towards substances and monitoring
Educational attainment, job, socioeconomic status
Percieved availability of drugs and alcohol
Peers (important for initiationonly no significant other, person with addiction living with pts
Neighborhood
Transitions- mobility- friends
GENETicssSSS
Substance misuse
Substance misuse- purpose not consistent with legal or medical guidelines
Perscription drug misuse: use of perscription drugs in any way that a doctor did not direct, includes use without a prescription use in in greater amounts, more often or longer than told to take them or use in any other way a doctor did not direct to use them
Hazardous use: increases risk of harmful consequences
Harmful use: causing damage to health (physical/mental)
Tolerance
Decrease in response to a drug as a result of repeated treatment with that drug
Pharmacokinetic- decreased quantitiy reaches site the drug affects
pharmacodynamic: reduced cellular response to repeated use
Behavioral either pharmacodynamics or drug independent learning (context dependent)
cross tolerance: between drugs of similar function or effect
substance use disorder DSM
A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12 month period
11 criteria into 4 categories: Impaired control, social impairment, risky uuse, pharmacological criteria
Impaired control
uses substance longer or in larger amounts than originally intended
Unseccessful attempts/desire to reduce use
Great deal of time spent getting substance or obsessing over substance
Craving for substance
Social impairment
Failure to fulfill major role obligations at work, school or home
Continued use despite recurrent social or interpersonal problems
Abandonment/reduction of social or recreational activities
Risky use
recurrent use in situations that are physically hazardous
Continued use despite knowledge of physical or psychological problems that are caused or exsacerbated by the substance
Pharmacological criteria
Tolerance and withdrawal
Symptoms of tolerance or withdrawal occuring solely during appropriate medical treatment with perscribed meds are NOT counted (opioids for pain control)
Addiction
Chronic, relapsing brain disease that is charcterized by compulsive drug seeking and use despite harmful consequences
Primary, chronic and relapsing brain disease characterized by an individual patholologically pursuing reward and or relief by substance use and other behaviors
Progressive illness that can lead to disability and death without treatment
Dual diagnosis and comorbidity
Antisocial personality and bipolar, (adhd is less)
50-60
schizophrenia
Neurobiology of addiction
several theories, no conclusinve answer, all models have short coming
stages of the addiction cycle
Binge intoxication–> tolerance, withdrawal, comprised social, occipational or recreational activites–>
Withdrawal negative Affect–> preoccupation with obtaining, persistent physical/ psychological problems–>
Preoccupation anticipation–> persistent desire, larger amounts taken than expected–> Binge
Disre formation
Wanting Dopamine
Addiction represents a dysregulation of incentive salience, reward (deficit), stress (surfeit) and executive function systems
Non addicted brain– saliency –> control stops–> drive
Addicted brain
Negative reinforcement
re- entering actie disease- relapse
drug induced, Cue induced- external and internal, stress induced
Progressive illness- even with longer sobriety, people often start out worse into the relapse than at the end of the last sobriety stretch
Assessment of substance use
Therapeutic assessment can help foster insight and motivation
Open ended questions, non judgmental
Drug use- Ask the same question twice, be concrete and specific (how many drinks does it take to get drunk), ask if they understand the question, ask if they understand the question, elicit pattern of use increase, decrease over time attemts to d/c
Context consequences and attidute
integrate drug use hisotory with life event history, builds understanding of triggers, level of insight insight, help seeking and accepting , context, consequences, attitude
integrate drug use history with life event history, builds understanding of triggers, level of insight, help seeking and accepting , other risk and supportive factors
treatment planning
no single treatment appropriate for all
About 11% of people who need treatment get it
However only 5% of the people defined as needing treatment think they need it
treatment planning according to the bio psycho social spiritual model
Good idea to refer to the aSAM dimension
treatment principles
Medication assisted treatment recovery: agonist therapy, partial agonist therapy, antagonist therapy
Psycho-social-spiritual modalitiesL individual therapy, group therapy, family therapy, peer support, social support, community support
Medication assisted recovery opioid use disorder
reduces- relapses rates, overdose deaths, hepatitis C, HIV infection andtransmission, drug related crime
Improves- brain health, work retention, physical health, mental health , preganaccy outcomes
Cognitive behavioral therapies
motivational enhancement therapy- short term, structured applied motivational interviewing and structured assessment and feedback
twelve step facilitation therapy- manual guided with emphasis on 12 step providing tools for recovery
individual drug counseling
manualized drug counseliing- stresses abstinence to achieve and maintain abstinence, 12 step participation
cognitive behavioral relapse prevention , recognizing triggers for drug use and rehearsing coping skills
